Thoracic Flashcards
1st and 2nd Line Treatment for patients with positive KRAS G12C mutations
First Line:
Platinum-based chemotherapy (± immunotherapy) is a recommended option for patients with KRAS mutations (eg, carboplatin plus paclitaxel).
Second/Subsequent Line:
Sotorasib
Adagrasib
1st Line Treatment options for patients with metastatic EGFR mutant positive lung adenocarcinomas & associated exon mutations
EGFR mutations: Exon 19 deletion & Exon 21 L858R
Preferred first line treatment: Osimertinib
Other first line options: Erlotinib (± bevacizumab or ramucirumab), afatinib, dacomitinib, or gefitinib
Third-generation ALK inhibitor that can overcome the largest number of acquired ALK resistance mutations
Lorlatinib
- Can overcome G1202R resistance mutation
First Line Treatment for metastatic advanced Non-squamous lung cancer with no targetable mutations, PDL1 < 1%
Pembrolizumab/Carboplatin/Pemetrexed
Pembrolizumab/Cisplatin/Pemetrexed
First Line Treatment for metastatic advanced Non-squamous lung cancer with no targetable mutations, PDL1 > 1%
Pembrolizumab mono therapy
Preferred First Line Treatment for Metastatic NSCLC with ALK mutation (3)
Alectinib, Brigatinib or Lorlatinib should be given as frontline therapy given their improved efficacy including superior brain penetration.
Preferred First Line Treatment for Metastatic NSCLC with ROS1 mutation (3)
Preferred: Entrectinib, Crizotinib, Repotrectinib
Indications for permanent discontinuation of trametinib
–Symptomatic congestive heart failure
–Absolute decrease in LVEF of greater than 20% from baseline that is below LLN
– If no improvement in LVEF after holding for 4 weeks
Adjuvant Osimertinib:
a. Indications
b. Dose & Duration
c. Most common AE
a. Indication: Resectable tumors stage IB – IIIA NSCLC with predominant non-squamous histology and EGFR exon 19 deletions or exon 21 L858R mutations
b. Treatment dose & duration: 80 mg daily for up to 3 years
c. Most common AEs: Lymphopenia, leukopenia, thrombocytopenia, diarrhea, anemia, rash, musculoskeletal pain, nail toxicity, neutropenia, dry skin, stomatitis, fatigue, and cough
Adjuvant treatment indications for localized disease after definitive therapy if PDL1 >1%
Pembrolizumab and Atezolixumab are approved following resection and platinum-based chemotherapy in patients with stage II to IIIA non-small cell lung cancer (NSCLC) whose tumors have PD-L1 expression on ≥ 1%
Preferred frontline option to offer patients who present with Metastatic/Advanced NSCLC [nonsquamous] that harbors an EGFR Exon 20 insertion mutation
Amivantamab + Carboplatin + Pemetrexed
Preferred frontline treatment for patients with metastatic NSCLC with NTRK1/2/3 Gene Fusion (3)
- Larotrectinib
- Entrectinib
- Repotrectinib
Preferred frontline and subsequent treatment for patients with metastatic NSCLC with MET Exon 14 Skipping Mutation (3)
- Capmatinib
- Crizotinib
- Tepotinib
Preferred frontline treatment for patients with metastatic NSCLC with BRAF v600E mutation (4)
- Dabrafenib/Trametinib
- Encorafenib/Binimetinib
- Dabrafenib monotherapy
- Vemurafenib mono therapy
Treatment option for patients with EGFR-mutated, advanced/metastatic NSCLC who develop progression on frontline Osimertinib
Amivantamab + Carboplatin + Pemetrexed as per the MARIPOSA-2 study
Neoadjuvant systemic therapy options for eligible patients with resectable NSCLC and required criteria (2)
Neoadjuvant therapy: Nivolumab plus platinum-doublet chemotherapy
Criteria:
- Stage IB (only tumors = 4 cm) to IIIA OR
- Stage IIIB (only T3 ≤7 cm , N2 = ipsilateral mediastinal and/or subcarinal LN) NSCLC
Which patients and what is recommended for adjuvant therapy for completely resected NSCLC and with PD-L1 of 1% or more who are negative for certain biomarkers?
Recommendation: Adjuvant Atezolizumab for patients with completely resected
- Stage IIB to IIIA
- Stage IIIB (only T3,N2)
- High-risk stage IIA NSCLC
Consolidation immunotherapy option with unresectable stage III NSCLC and without disease progression after treatment with definitive concurrent platinum-based chemoradiation
Patients with stage III disease are recommended for consolidation with Durvalumab, irrespective of PDL1 status after with definitive concurrent platinum-based chemoradiation
Adjuvant treatments approved for stage IIIA NSCLC
EGFR 19 or 21 deletion: Osimertinib x3 yrs
ALK positive: Alectinib x2 yrs
PDL1 > 1%: Atezolizumab x1 yr
Irrespective of PDL1 status: Pembrolizumab x 1 yr
First Line Treatment of patients with stage IV squamous NSCLC with PD-L1 TPS > 50%
PD-L1 TPS > 50%:
Pembrolizumab
Atezolizumab OR
Cemiplimab monotherapy
First Line Treatment of patients with stage IV squamous NSCLC with
A. PD-L1 Expression TPS, 1%- 49%
B. Unknown or PDL1 TPS <1%
A. PD-L1 Expression TPS, 1%- 49%:
- Pembrolziumab + Carboplatin + paclitaxel (or nab-paclitaxel) OR
- Cemiplimab + carboplatin + paclitaxel (or nab-paclitaxel)
B. Unknown or PDL1 TPS <1%:
Pembrolziumab + Carboplatin + paclitaxel (or nab-paclitaxel)
Only statin approved for lorlatinib induced hyperlipidemia
Rosuvastatin
Cardiac AE of each TKI + which of the following is the only one to cause high triglycerides and cholesterol?
Lorlatinib
Brigatinib
Alectinib
Crizotinib
Ceritinib
- Lorlatinib: AV Block + Hypercholesterolemia
- Brigatinib: Bradycardia
- Alectinib; Bradycardia
- Crizotinib: QTC Prolongation and Bradycardia
- Ceritinib: QTC Prolongation and Bradycardia
First and Second Line treatment for metastatic NSCLC with KRASG12C mutation
First Line: SOC with platinum + immunotherapy or immunotherapy
Second Line/Subsequent therapy:
- Sotorasib
- Adagrasib
Treatment of metastatic ROS1 NSCLC with brain mets (2)
Entrectinib or Repotrectinib
